The University of Texas at Dallas - Alliance for Physician Leadership CME Evaluation Form
2/7/26-3/7/26 Competencies of Effective Leaders
Name
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First Name
Last Name
Credentials (as you want them to appear on your certificate)
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Please Select
MD
DO
Other
Email
*
example@example.com
How many CME Credits are you claiming? (Maximum 32 Hours)
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Activity Review
Please indicate your level of agreement with the following statements:
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Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
The speaker(s) were effective at presenting the content
The information presented is relevant to my clinical practice
This activity will improve my patient education skills
This activity will improve patient outcomes
This activity increased my competence of the subject matter
The educational format was appropriate for the setting, objectives, and desired results of this activity
Use the space below to elaborate on any of the above:
Describe at least one new piece of information you learned from participating in this activity.
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Based on what you have learned, what changes do you plan to make in your practice?
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Rate your confidence in applying your new learning into practice:
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1
2
3
4
5
Not Confident
Very Confident
1 is Not Confident, 5 is Very Confident
What barriers to implementing changes do you experience in your practice? Check all that apply.
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Cost constraints
Insurance/Reimbursement issues
Lack of time with patients
Overwhelming amount of information
Lack of administrative or management support, workflow issues
Lack of authority to implement changes
Gaps in my knowledge and training
Lack of support staff
Gaps in support staff knowledge and training
I do not anticipate any barriers to implementing changes
Other
What areas of your practice could be enhanced or improved with additional education?
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